Personalized Medicine in Undergraduate Medical Education: a Spiral Learning Model

Abstract

Educational strategies to introduce medical students to scientific advances are needed as evidence continues to evolve regarding their clinical application in personalized medicine. Our overall project goal is to design an evidence-based, clinically relevant, personalized medicine curriculum spanning the 4 years of undergraduate medical education.

Background

Despite efforts to introduce cutting-edge biomedical advances into undergraduate medical curricula, only a small percentage of medical students feel that their education has prepared them for an era of personalized medicine [1]. While the majority of undergraduate programs include genomic topics in the first 2 years, personalized medicine content is included in only 21% of curricula [2]. Along with an individual’s genomic make-up, personalized medicine takes into account additional environmental factors that could shape one’s health [3]. Therefore, we will use the term personalized medicine, instead of genomic medicine, to describe this intervention.

Many physicians feel unprepared and are reluctant to apply scientific advances to everyday practice [4, 5]. Furthermore, integration of basic science and emerging research throughout the undergraduate medical curriculum continues to be a strategic priority of most institutions. However, barriers to provide such content include heavy student academic workload and insufficient instruction regarding scientific research [6, 7]. One approach to increase student exposure to personalized medicine is to incorporate a curricular thread spanning the entire 4 years of undergraduate medical education (UME) [8]. Here, we describe the design of a spiral learning approach to provide such content and our experience implementing three pilot activities.

Activity

The Paul L. Foster School of Medicine (PLFSOM) offers a highly integrated curriculum across the 4 years of UME. Our goal is to develop 5 sessions covering scientific advances in personalized medicine. Three of these will be embedded within the preclinical years, with an additional session in year 3 and an elective course offered in year 4. These will integrate into our existing curriculum using a spiral learning model by building on foundational concepts with progressively deeper content coverage [9, 10]. Previously acquired knowledge of genomic and environmental factors will be reviewed through increasingly complex patient scenarios that apply next-generation sequencing, stem cell therapy, biomarkers, and immunotherapy. These will be led by a panel of discipline experts in the fields of biochemistry, cell biology, clinical genetics, internal medicine, immunology, and microbiology, to mirror the interdisciplinary and collaborative nature of clinical care and research.

Therapeutic Use of Stem Cells

As a springboard, a 2-h activity for 1st year medical students entitled “Introduction to Translational Research: Therapeutic Use of Stem Cells” addressed basic stem cell biology and the ongoing efforts to use stem cells in regenerative therapies. Material included an introduction to existing types of stem cells, related terminology, biological characteristics, and potential therapeutic applications. Utilizing current clinical research scenarios (including renal, cardiac, and pulmonary cases), students discussed in small groups the potential challenges and solutions utilizing stem cell therapies and presented their approaches to the class for further discussion.

Hot Topics in Cancer Precision Medicine

A 2-h activity entitled “Hot Topics in Cancer Precision Medicine” was implemented as a bridge between various clerkships in the third year. The cases introduced emerging areas of cancer genomics, cancer immunotherapy using dendritic cells and chimeric antigen receptor (CAR) T cells, and clinical uses of clustered regularly interspaced short palindromic repeats (CRISPR) technology. These cases challenged students to consider environmental and epigenetic contributions to cancer development, progression, and response to immunotherapy. This activity incorporated review of previous material and self-quizzing through Poll Everywhere (PollEv) software.

Fourth Year Elective

During a 2-week elective course, students were tasked to research and then respond to prompts to a topic in personalized medicine. Students received evaluations by the faculty based on their analyses of the questions and use of scientific literature. Peer-to-peer evaluation was also incorporated for this elective course. The student’s final grade was based on a presentation to faculty and peers at the end of the course. Future activities will allow students to integrate the conceptual knowledge through clinical lab correlates and simulations.

Results

Feedback indicated that the sessions were well received. We sought to further evaluate the outcomes of “Hot Topics in Cancer Precision Medicine” using a one-group pre-test and post-test observational analysis. An anonymous questionnaire was completed at the beginning and end of the session using PollEv software.

The majority of the students (55 out of 66 students, 83%) found the material to be useful. Approximately 90% of the student-respondents would seek additional opportunities to learn about personalized medicine and implement related technologies for the benefit of their patients. In the pre- and post-surveys, the students were asked to evaluate their ability to explain to others the clinical uses of next-generation sequencing, dendritic cell therapy, and chimeric antigen receptors. Answer selections were “Agree” or “Disagree.” As we were interested in determining improvement in student responses based on the pre- and post-surveys, we utilized the McNemar statistical test. There was a statistically significant difference between the numbers of participants moving from Disagree to Agree, compared with those who moved in the other direction. Thus, the majority of students moved from being “unable to explain” to “being able to explain” clinical uses of next-generation sequencing, dendritic cell immunotherapy, and CAR T cell therapy (Table 1).

Table 1.

Ability for students to explain clinical uses of next-generation sequencing (A), dendritic cell immunotherapy (B), and chimeric antigen receptor T cell therapy (C). Students were asked to evaluate their ability to explain clinical uses of the various translational content with answers being “Agree” or “Disagree”. Tables show a statistically significant difference in the number of responses moving from being unable to explain to being able to explain clinical uses of next-generation sequencing (A), dendritic cell immunotherapy (B), and CAR T cell therapy (C). A non-parametric test for paired nominal data (McNemar statistical test) was used to determine improvement in students’ abilities based on the pre- and post-survey responses

Discussion

Cutting-edge scientific discoveries are commonly underrepresented in UME and pose a significant challenge for medical educators in the face of rapidly evolving scientific information [2]. Furthermore, little consideration is given to building on previous concepts of personalized medicine. We have developed an innovative, personalized medicine curricular thread to keep students abreast of important scientific advances through case-based scenarios that are presented by a panel of discipline experts. Concepts and technology in emerging translational research are challenging and constantly changing; thus, each activity builds on and extrapolates previously presented information using the spiral learning model [10]. In each successive session, topics are revisited with increasing complexity and include review material with robust self-quizzing to emphasize the spiral progression of knowledge as depicted in Fig. 1.

Fig. 1.

Chronology and outline of personalized medicine modules. a Three sessions will be embedded within the preclinical years 1 and 2, with an additional session in year 3 and an elective course offered in year 4. A brief review of previous modules will be given to highlight the spiral learning nature of the material. b Learning materials and format are indicated for the 4 single sessions and the elective course

Some aspects of personalized medicine are covered in foundational genomic education initiatives in medical schools; for example, The Medical School Core Curriculum in Genetics in 2013 published by the Association of Professors of Human Genetics and iterations by the Association of American Medical Colleges are used to shape current UME content [11, 12]. Recent published reports of genomic medicine curricula at the undergraduate level include various educational methods; however, most overlook emerging translational content due to the need for continuous revision and updating, along with the challenge of outdated educational materials and textbooks [8].

Prior to implementing this project, the Paul L. Foster SOM curriculum included related foundational topics such as genome organization and regulation, genetic variation, population genetics, inheritance, and the biochemical and genetic principles of cancer: these are covered in various formats including in-class didactic lectures and team-based activities. In addition, discussion-based activities allow students to delve into ethical issues in personalized medicine. Here, students will be encouraged to apply early knowledge gained in their core classes to personalized medicine applications that incorporate emerging translational concepts.

Outcomes from these piloted interventions demonstrated student interest in learning about and applying advances in personalized medicine to their future practice. Following “Hot Topics in Cancer Precision Medicine,” there was an increase in medical students’ comfort in explaining current biomedical advances to others and a positive outlook regarding the activities.

Our initial implementation of this initiative has some overall limitations including the need to phase the activities into the curriculum across several academic years rather than all at once. Due to this phased-approach, we were unable to uniformly assess their impact. As we move forward, we will develop an appropriate umbrella evaluation to determine the overall impact and learner satisfaction.

In summary, our goal is to promote core competencies regarding scientific frontiers in personalized medicine to empower medical students to utilize scientific advances in their careers. Strengthened with a deeper understanding of these concepts and technologies, students will have a greater appreciation of their use in modern medicine.

Authors’ Contributions

All authors discussed the results and contributed to the final manuscript. The first two authors contributed equally to this work.

Data availability

NA

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Approval

IRB exempt

Code Availability

NA